Silent pituitary macroadenoma co-secreting growth hormone and thyroid stimulating hormone.

Silent pituitary adenomas are a group of tumors showing heterogenous morphological features with no hormonal function observed clinically. To date no explanation has been provided as to why these tumors remain "silent". We report a case of a silent macroadenoma with both growth hormone (GH) and thyroid stimulating hormone (TSH) staining and secretion but with no clinical manifestations, in particular, the absence of features of acromegaly or hyperthyroidism. The relevant literature is reviewed.     

The relation between serum levels of osteoprotegerin and postoperative epidural fibrosis in patients who underwent surgery for lumbar disc herniation

OBJECTIVES: Epidural fibrosis (EF) is a part of the normal physiological tissue response to laminectomy and it is an important cause of failed back surgery syndrome (FBSS). Osteoprotegerin (OPG) is a soluble member of the tumor necrosis factor receptor family, and is expressed in high concentrations by a variety of tissues and cell types. The objective of this study was to evaluate the relationship between serum OPG levels, and the existence of postoperative EF in patients with lumbar disc herniation. It has been suggested that cytokines and growth factors, which play a role in the wound healing, may enhance the expression of OPG. METHODS: Forty women who underwent surgery for lumbar disc herniation were included in this study. Postoperative MRI was performed to assess EF in all patients. RESULTS: The serum OPG levels of subjects with postoperative EF were significantly higher than those of subjects without postoperative EF (4.72 +/- 0.27 versus 3.25 +/-0.41 pmol/l; p=0.005) DISCUSSION: Although the role of OPG in the development of EF is poorly understood, our results suggest that elevated levels of serum OPG are associated with and may play a role in the pathogenesis of fibrotic process.     

Analysis and prevalence of inflammatory cells in subtypes of lumbar disc herniations under cyclooxygenase-2 inhibitor therapy

OBJECTIVE: The aim of the present study was to analyse inflammatory cells in lumbar disc tissue under cyclooxygenase-2 (COX-2) inhibitor therapy, to detect their prevalence in different subtypes of lumbar disc herniations and to assess the influence of inflammatory reactions in herniated disc tissue on postoperative outcome.METHODS: In this prospective study, intervertebral disc specimens were obtained from 50 patients. All the patients were given COX-2 inhibitor therapy (Rofecoxib) 25 mg/day for 10 days before surgery. The herniated disc specimens were routinely fixed in a 10% buffered formaline solution and paraffin-embedded; 5 microm thin sections were stained with monoclonal antibodies CD-68 for macrophages, CD-45 RO for T cells and CD-20 for B cells. The specimens were microscopically examined and classified by two independent examiners in a blinded manner.RESULTS: CD-68 macrophages were evident in herniated lumbar disc tissue in 40% of the cases, but abundant inflammation was observed in only 18% of the cases. Macrophages were significantly common in sequesters with a prevalence of 80%, and no macrophages were observed in the protrusions. We obtained the best outcome scores in the patients with a sequestrated lumbar disc herniation.CONCLUSION: Although most of the specimens from all the patients showed no significant inflammatory reaction, maybe due to COX-2 inhibitor therapy, they all needed surgery with no relief of the symptoms despite conservative therapy. Nerve root compression still seems to be the leading pathomechanism.     

Right basal ganglion hypoperfusion in obsessive compulsive disorder patients demonstrated by Tc-99m-HMPAO brain perfusion spect: a controlled study

The aim of this study is to demonstrate the regional cerebral blood flows (rCBF) of obsessive-compulsive disorder (OCD) patients compared to controls by using Tc-99m-HMPAO SPECT. Sixteen OCD and seven control subjects were admitted into the study. Yale-Brown Obsessive Compulsive Rating Scale (Y-BOCS), Hamilton Depression Rating Scale (HDRS), and Hamilton Anxiety Rating Scale (HARS) were applied to the patients. The rCBF was found to be decreased in right basal ganglion in OCD patients. The right basal ganglion rCBF was negatively correlated with Y-BOCS total and compulsion scores. The left thalamus rCBF was negatively correlated with Y-BOCS obsession score. Right and left cingulate rCBF were negatively correlated with HDRS score. The results indicating hypoperfusion in right basal ganglion in OCD patients support previous findings about dysfunction of frontal-subcortical circuits in this disorder.     

Lumbar meningeal hamartoma and epidermoid cyst associated with spinal dysraphism in an elderly patient

Meningeal hamartoma associated with spinal dysraphism in an elderly patient is an extremely rare clinical presentation. A 62-year-old woman who progressively developed gait disturbance and urinary retention was admitted to our hospital. Magnetic resonance imaging (MRI) revealed a large cystic mass associated with a dermal sinus at the L4-L5 level. MRI was useful in the diagnosis and determination of this lesion. However, preoperative differential diagnosis of the tumor was not possible based on neuroimaging evidence. The diagnosis of meningeal hamartoma was based on the histological and immunohistological findings of the specimen obtained from the tumor. Meningeal hamartoma associated with spinal dysraphism should be kept in mind, even in adult cases. In this article, we also discuss the radiological and pathological appearance of this rare clinical entity.     

A proposal for a new and more practical grading scheme for pancreatic ductal adenocarcinoma

There is no uniformly applied grading system for pancreatic ductal adenocarcinoma (DA). The scheme advocated by the WHO is essentially that of Kloppel et al, and is based on the "highest grade" focus. Although it is precise with good prognostic value, it is unfortunately not widely applied, largely because of the lack of recognition and partly because of its complex nature (interpretation of multiple parameters). Furthermore, it is fundamentally different from the one used in Japan, which evaluates the overall pattern. To establish a more widely applicable, practical, and clinically relevant grading system, a scheme similar to Gleason's scoring system was developed and tested on 112 cases of resected pancreatic DA and was compared with the WHO system. In the grading system devised, patterns (P) of infiltration were classified as follows: P1, well-defined glands with easily discernible contours; P2, fused or poorly formed glands with ill-defined contours; P3, nonglandular patterns. A score was then obtained by the summation of the predominant and the secondary patterns. Scores < or =3 (at least some well-formed glands and no nonglandular pattern) was graded as G1, 4 as G2, and > or =5 (at least some nonglandular patterns and no well-formed glandular pattern) as G3. Seventy-three percent of the cases displayed mixed patterns, with disparate patterns (P1 with P3) in 13%, confirming the high degree of heterogeneity of DA. There was a significant correlation between grade and survival, better than the correlation between survival and either the major or minor patterns evaluated separately. The median survival for G1, G2, and G3 were 22, 14, and 8 months; 1-year survival 68%, 44%, and 33%; 2-year was 67%, 11%, and 0%; and 3-year was 23%, 4%, and 0%, respectively (P = 0.0019). In a multivariate analysis, correlating survival with grade, tumor size, and lymph node status, the grade was the strongest independent predictor of survival. Odds ratio of dying of disease were 3.56 (P < 0.0001) in G3 versus G1, 1.79 (P = 0.058) in G2 versus G1, and 1.98 (P = 0.03) in G3 versus G2. Compared with this, the same odds ratio were 1.17 (P = 0.01) in tumors >2 cm versus < or =2 cm and 1.78 (P = 0.01) in cases with positive versus negative lymph nodes. The WHO grading scheme was not found to have as good a correlation with survival in this study, with WHO grade 2 showing a better survival than 1. The reproducibility of both the proposed grading system and that of WHO were found to be moderately good (with kappa values of 0.43 and 0.44, respectively), when 32 slides of DA were graded by four independent observers. The grading scheme for pancreatobiliary adenocarcinoma proposed here is highly applicable because it is practical and readily adoptable. It reflects biologic characteristics of ductal carcinoma (prominent tubule formation and tumor heterogeneity). Most importantly, it is clinically relevant with good prognostic value. Lastly, it is also applicable for use in research, by utilizing "patterns," even in small specimens like microarrays or biopsies.     

Protective effect of ischemic preconditioning on retinal ischemia-reperfusion injury in rats

BACKGROUND: A short period of ischemia can induce remarkable tissue resistance to the deleterious effects of subsequent ischemia and reperfusion. We performed a study to investigate the effect of ischemic preconditioning on retinal ischemia-reperfusion injury in rats. METHODS: Ten Wistar albino rats were divided into two groups of five animals (10 eyes): one group underwent 5 minutes of ischemic preconditioning (achieved by clamping the common carotid arteries at the time of vertebral artery cauterization), and the other did not (control group). In both groups, the vertebral arteries were occluded bilaterally with an electric needle coagulator under an operating microscope. Forty-eight hours later the rats were reanesthesized, and both common carotid arteries were clamped to interrupt blood flow.The duration of ischemia was 30 minutes. The clamp was then removed to enable reperfusion for 4 hours. The animals were killed by decapitation, and retinal sections were evaluated under light and electron microscopy.The signs of ischemia-reperfusion injury (cellular degeneration, vacuolization between retinal layers, increase in retinal thickness due to edema, mononuclear cell infiltration and apoptotic cell count) were recorded. RESULTS: Light microscopy of retinal sections from rats in the ischemic preconditioning group showed a well-preserved retinal structure. The mean thickness values (and standard deviation [SD]) for the inner nuclear layer (104.0 microm [2.54 microm] vs. 49.0 microm [ 10.83 microm]) and inner plexiform layer (134.8 microm [10.13 microm] vs. 88.5 microm [17.46 microm]) were significantly higher in the control group than in the preconditioning group (p = 0.009), indicating increased retinal thickness in the former group due to tissue edema resulting from ischemia-reperfusion injury.The mean mononuclear cell count (6.67 [SD 1.97] vs. 2.5 [SD 1.0]) and apoptotic cell count (18.2 [SD 5.7] vs. 5.3 [SD 1.0]) were significantly higher in the control group than in the preconditioning group (p = 0.002), indicating an inhibitory effect of ischemic preconditioning on leukocyte infiltration and apoptotic cell death. INTERPRETATION: Ischemic preconditioning attenuated ischemia-reperfusion injury in the rat retina.